Is Snoring Bad For You?

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Is Snoring Bad For You?

• Dr. Shanthi Paramothayan
• BSc MBBS PhD LLM MScMedEd FHEA FCCP FRCP
• Consultant Respiratory Physician
• Honorary Senior Lecturer
• St. Helier University Hospital
• 8th September 2012

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History

• Mr. AN
• 35 years Non smoker
• Cab driver Minimal alcohol
• Divorced Poor sleep
• Depressed Fatigue
• Snores loudly Un-refreshed
• Daytime somnolence

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History

• New girlfriend reports
• Loud snoring
• Apnoeas
• Snorts and grunts

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Examination

• Obese Wt 182 kg, Ht 190 cm, BMI 50
• Collar size 23 inches
• BP 150/95
• Narrow oropharynx
• Chest clear
• Epworth Sleepiness Score 16

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Epworth Sleepiness Score

• How likely are you to doze off or fall asleep
  during the following situations, in contrast to
  just feeling tired?
• Score of 0 to 3 where 0 would never dose 1
  slight chance 2 moderate chance 3 high
  chance.
• Situation Score
• Sitting and Reading
• Watching TV
• Sitting inactive in a public place
• As a passenger in a car for an hour
• Without a break
• Lying down to rest in the afternoon
• Sitting and talking to someone
• Sitting quietly after lunch (no alcohol)
• In a car while stopped in traffic

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Epworth Sleepiness Score

• Score of lt 6 Normal
• Score of gt 8 Possible sleep disordered breathing
• Score of gt 12 Probability of OSA
• Score of gt 16 High probability of OSA
• Score of gt 20 Consider narcolepsy
• Maximum score 24

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So what is the diagnosis?

• Differential diagnosis of snoring
• Simple snoring consider ENT causes (e.g
  deviated septum). May be positional and
  exacerbated by alcohol, sedatives
• Upper airways resistance syndrome (UARS)
• Obstructive sleep apnoea (OSA)

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Hypersomnolence

1. UARS
2. OSA
3. Narcolepsy
4. Obesity-hypoventilation (Pickwickian) syndrome
5. Insomnia/other sleep related disorders
6. Restless Leg Syndrome (periodic limb movement)
7. REM behaviour disorder
8. Chronic insufficient sleep

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Obstructive Sleep Apnoea

• Apnoea means without breath in Greek
• People with OSA stop breathing repeatedly during
  their sleep, often for a minute or longer, even
  up to 100 x every night
• Apnoea complete obstruction of airways for gt 10
  secs
• Hypopnoea Partial obstruction of airways (30 50
  ) for gt 10 secs
• AHI apnoea/hypopnoea index (no / hour, same as
  RDI)
• Mild OSA AHI of gt 10 / hr
• Moderate OSA AHI of gt 20 / hr
• Severe OSA AHI of gt 30 / hr

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Obstructive sleep apnoea and upper airways
resistance syndrome

• UARS
• Snoring with brief, repetitive arousals due to
  increases in resistance to airflow and increased
  respiratory effort
• Negative intrathoracic pressure ? autonomic and
  CV changes? hypertension. No oxygen desaturations
• Sleep fragmentation results in daytime
  somnolence
• OSA
• Snoring with apnoeas and hypopnoeas and oxygen
  desaturations (? 4 from baseline)
• The AHI is a continuous variable like BP, so
  separating normal from abnormal is difficult.

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Epidemiology of OSA

• Common 5 of women and 10 of men aged over 35
  (USA Wisconsin cohort study, 9-24 in M and 4
  9 in F)
• MF 2-3 1 (? in F after menopause)
• Prevalence increases with age
• Race Prevalence gt in African-Americans
• Mortality and Morbidity retrospective data
  suggest the greater mortality in patients with
  AHI gt 20 / hour

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Risk Factors for OSA

• Obesity BMI gt 25, collar size gt 17 inches
• Age loss of muscle mass in airways and neck and
  excess fat
• Nasal problems that impede airflow
• Enlarged tonsils and adenoids (children)
• Hypothyroidism
• Acromegaly
• Other structural abnormalities retrognathia,
  micrognathia
• Amyloidosis, neuromuscular disorders, Marfans,
  Downs
• Can be exacerbated by supine position, alcohol
  and sedatives

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Low threshold for referral in

• Overweight patients
• Snoring or disturbed sleep
• Unexplained tiredness
• Unexplained sleepiness
• Lack of concentration, memory, libido
• Resistant hypertension (requiring many
  antihypertensives
• Metabolic syndrome Diabetes, HT,
  hypercholesterolaemia
• Cardiovascular disease (heart failure,
  arrhythmias,

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So what happens in OSA?

• Site of obstruction is soft palate, extending to
  the region at the base of the tongue (no rigid
  structures to hold airway open)
• When awake, muscles in the region keep passages
  open
• When asleep, muscles relax, and there is reduced
  neuromuscular activity, causing airway collapse
  and obstruction of airway
• This results in an oxygen desaturation
• When breathing stops, the sleeper awakens
  (arousal) for a few seconds and there is a rise
  in BP
• Repeated arousals cause sleep fragmentation (no
  REM sleep) and un-refreshed sleep

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Normal
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Sleep apnoea-hypopnoea syndrome
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Upper airway resistance increases during sleep
in normal subjects
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Typical presentation of OSA

• Symptoms are insidious and often present for
  years
• Snoring, loud and habitual and bothersome to
  others
• Witnessed apnoeas that end with a loud snort
• Gasping and choking sensations
• Restless sleep, frequent arousals, nocturia
• Feeling un-refreshed, morning headaches
• Excessive sleepiness during day
• Poor concentration, memory, libido
• Problems with family and work
• Road traffic accidents (RTA)

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Approach to a patient with possible OSA

• Get clear history and talk to witnesses (partner)
• Driving history and occupation (truck drivers,
  train drivers)
• Assess daytime sleepiness (ESS) and other
  symptoms
• Weight, height and calculate BMI
• Collar size
• Oropharynx (tonsils)
• Nasal airflow
• Blood pressure
• Cardiovascular and respiratory examination

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Investigating patients with possible OSA

• Bloods FBC, UEs , glucose, thyroid function
• Epworth sleepiness score
• (Multiple sleep latency test)
• If necessary ECG, CXR
• ENT referral

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Investigating patients with possible OSA

• Overnight pulse oximetry
• Overnight limited sleep study oximetry, thoracic
  and abdominal wall movement, oronasal airflow,
  snore volume, BP
• Full polysomnography as above plus
• Leg movements (anterior tibialis EMG) and video,
  
• Sleep stages (EEG, EMG, EOG)
• ECG and blood pressure

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Consequences of OSA

• Untreated OSA is related to a significant
  mortality risk, 3X (Sleep, American Heart
  Association, American College of cardiology,
• OSA is a risk factor for developing nocturnal
  hypertension (independent of other factors
  (Davies, Thorax 1998)
• Recent evidence that OSA causes hypertension and
  treatment with CPAP improves BP (Becker et al,
  Circulation 2003, 10768-73, Nieto et al, JAMA
  2000, 2831829-1836, Peppard P, N Engl J Med
  2000, 342 1378-1384)
• OSA increases risk of stroke, heart block and MI
• Risk of OSA is increased in patients with
  pulmonary hypertension
• Link between OSA and heart failure (also with
  central sleep apnoea)
• Increased risk of RTA

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Evidence of link between OSA and CV disease

• Animal models
• Epidemiology
• Association long suspected ? Confounding factors?
• Wisconsin Sleep Cohort study
• 18 year follow up of 1522 (30-60 yrs) with mild,
  moderate, or severe OSA or no OSA
• Mortality was 19 with severe OSA v 4 with no
  OSA
• Sleep study (Australia)
• 14 year study of 380
• Moderate-to-severe sleep OSA was an independent
  risk factor for dying (33 in severe OSA v 7.7
  in no OSA)

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Mechanism of increased cardiovascular morbidity
in OSA

• OSA associated with increased CV morbidity
• Intermittent hypoxia increases formation of
  reactive oxygen species and oxidative stress
• Reactive oxygen species cause rupture of unstable
  atherosclerotic plaques
• Inflammatory pathways activated
• Inflammatory cytokines and adhesion molecules
  cell/leukocyte/platelet interaction
• Endothelial dysfunction

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Syndrome Z

• Hypertension
• Central Obesity Syndrome X
• Insulin resistance
• Hyperlipidaemia
• OSA Syndrome Z
• So suspect OSA in patients with above risk factors

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Management of patients with OSA

• Depends on severity of OSA and symptoms
• General
• Weight reduction (dietician, medication)
• Advice on sleep position (tennis ball !)
• Avoidance of alcohol and sedatives
• Treat nasal congestion
• Try devices to stop snoring (e.g snorban)
• Information, telephone numbers and websites
• Information about Driving Patient must inform
  DVLA if they are being investigated for OSA

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Management of patients with OSA

• Oral appliances
• CPAP
• Medication Modafinil (Provigil)stimulant. For
  patients still symptomatic despite CPAP
• Surgery uvulopalatopharyngoplasty (UPPP),
  craniofacial reconstruction, tracheostomy

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Oral Appliances

• Oral appliances move tongue or mandible forward
• Suitable as 1st line therapy for mild OSA if
  patient doesnt tolerate CPAP
• Not as effective as CPAP (Engleman, 2002)
• Mandibular advance devices move lower jaw forward
• Tongue-retaining devices pull tongue forward
• Should be fitted by specialist dentist/maxillofaci
  al surgeon
• Side effects TMJ pain, excessive salivation

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CPAP (Continuous Positive Airways Pressure)

• Treatment of choice in moderate and severe OSA
• CPAP improves snoring, sleep quality, daytime
  sleepiness, mood, cognitive function, QOL
  (Becker, 2003)
• CPAP decreases BP and has other cardiovascular
  benefits in patients with OSA (RCT evidence)
• Compliance is a major problem 50 70 use it
  regularly and significantly
• Common side effects rhinorrhoea, dry mouth, dry
  eyes, nose bleeds, claustrophobia, aerophagia
• Need regular assessment, advice, help with mask
  fitting, humidifier etc so need competent
  technical staff
• Patients with OSA can drive once established
  effectively on CPAP

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So what happened to my cab driver?

• Overnight limited sleep study showed significant
  OSA
• Patient given information about weight reduction,
  referred to dietician
• Patient referred urgently for CPAP
• Patient advised NOT to drive and to inform DVLA
  until established on CPAP

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Now what about you?

• Do you snore?
• What is you ESS?
• If you snore and your ESS is gt 12

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Central Sleep Apnoea

• Absent/reduced ventilatory drive
• Congenital
• Ondines curse
• Acquired
• Destructive brain lesions
• Neuromuscular disease
• Severe obesity
• Chest wall abnormalities

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Conclusions

• OSA is common. Need increased awareness
  (especially GPs) and referral for sleep study
• Pulse oximetry suitable for majority with OSA but
  will miss UARS and mild OSA, or patients with
  hypoxia for other reasons
• Limited sleep study can be done at home and will
  be sufficient for the majority with OSA but may
  miss other problems
• Increasing evidence that OSA is a significant
  risk factor for systemic hypertension,
  cardiovascular disease, pulmonary hypertension
  and all cause mortality
• Evidence that treatment of OSA reduces risk
• OSA responsible for a significant number of road
  traffic accidents
• CPAP is the treatment of choice for OSA

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